OBJECTIVES: To understand alcohol use trends and alcohol-related harm among youth in South Africa (SA) between 1998 and 2008, and discuss implications for the current alcohol policy process. METHODS: A review was conducted of 4 national prevalence and 2 sentinel surveillance studies. Data were extracted to Epi Info (version 7) and chi-square analyses undertaken. RESULTS: Lifetime alcohol use remained stable but high at 20 -25% and 49.1 - 49.6% according to South African Demographic and Health Survey (SADHS) and Youth Risk Behaviour Survey (YRBS) data, respectively. Age of initiation remained stable; 12% of adolescents initiated alcohol use prior to age 13 years. Significant gender differences existed with more males having ever consumed alcohol, engaged in binge drinking, and driven or walked under the influence of alcohol (DUI and WUI, respectively). Binge drinking among females increased significantly from 27% to 36% (SADHS) and 18% to 27% (YRBS). DUI and WUI increased. Homicide/ violence, suicide and unintentional deaths were significantly associated with blood alcohol concentration (BAC). CONCLUSIONS: Although SA has made significant strides in alcohol control and prevention of alcohol-related harm over the past decade, early alcohol initiation remains a concern and binge drinking is increasing, especially among females. Significant associations exist between BAC and alcohol-related fatalities. Findings imply that regulatory policies are inadequate; additional efforts are required to ensure that control strategies translate into a reduction in harmful alcohol use by SA youth.